Social Services Coordinator

Location: Hallock, MN
Status: Non-Exempt | Full-Time

Pay Range: $ $39.75 hourly

About Kittson Healthcare:

Since 1922, Kittson Healthcare has proudly provided continuous service to the citizens of Kittson County and surrounding areas. Today, we are a 12-bed acute care federally designated Critical Access Hospital and a 50-bed long-term care facility, which also includes a home healthcare agency, an 8-bed assisted living facility, and ambulance services. Our campus includes a medical clinic in Hallock and a satellite clinic in Karlstad, MN. We strive to provide highly personalized care to every patient and resident—we don't see them as numbers, but as family, neighbors, teachers, and community members.

Department: Social Services

Reports To: CEO
Supervises: No one

Job Summary:

The Social Services Coordinator in a rural healthcare setting is responsible for overseeing all medically related social service aspects within the facility, including resident and patient assessments, care plan development, discharge planning, family communication, community resource coordination, and advocacy, ensuring resident's emotional and psychosocial needs are met while adhering to regulatory compliance,

Primary Responsibilities Include:

Hospital (Inpatient & Emergency Department)

• Service Coordination

• Conduct psychosocial assessments for emergency, acute care, and swing-bed patients.

• Facilitate safe discharge planning, including home health, rehabilitation, hospice, or nursing home placement.
• Coordinate interdisciplinary case review meetings with nursing, medical staff, therapy, and ancillary departments.

• Resource Connection

• Connect patients and families with financial assistance programs, transportation services, community mental health, substance-use resources, and public benefits.

• Assist uninsured or underinsured patients with applications for coverage or charity care.

• Advocacy

• Advocate for patient rights and preferences during treatment planning and discharge decisions.

• Address concerns related to capacity, guardianship, family conflicts, or safety issues.

• Follow-Up

• Conduct post-discharge check-ins for high-risk patients (e.g., readmission risk, limited social support, behavioral health needs).

• Maintain communication with receiving agencies to ensure continuity of care.

• Care Planning

• Develop individualized care plans objectives addressing social, emotional, and environmental needs.

• Collaborate with medical staff to integrate psychosocial interventions into overall patient care.

Outpatient Clinic

• Service Coordination

• Support primary care providers by assisting patients with complex social or behavioral health needs.

• Coordinate referrals to specialty care, behavioral health, substance-use treatment, and community support programs.

• Resource Connection

• Guide patients in accessing community resources such as housing assistance, food security programs, utility support, and chronic-disease management programs.

• Advocacy

• Advocate on behalf of vulnerable patients to ensure treatment adherence barriers are addressed.

• Follow-Up

• Track referred services and ensure completion of screenings, specialist visits, or support service contacts.

• Monitor ongoing social needs for patients with chronic conditions.

Nursing Home / Long-Term Care

• Service Coordination

• Complete required psychosocial assessments on all new residents.

• Participate in MDS (Minimum Data Set) processes and interdisciplinary care conferences.
• Coordinate transitions between hospital, home, and long-term care settings.

• Resource Connection

• Help residents and families access financial benefits, durable medical equipment, mental health services, or legal/guardianship support.

• Provide information on end-of-life planning resources, hospice, and advance directives.

• Advocacy

• Serve as resident advocate, ensuring rights, autonomy, and preferences are upheld.

• Mediate family/resident issues and support staff in addressing behavior or adjustment concerns.

• Follow-Up

• Monitor resident adjustment and satisfaction during admission and routinely thereafter.

• Follow up on behavioral health referrals and care plan changes.

• Care Planning

• Develop individualized care plan objectives addressing psychosocial well-being, adjustment, emotional support needs, and discharge goals.

• Collaborate with nursing, dietary, therapy, and activities departments to optimize resident quality of life.

Cross-Departmental Responsibilities Include:

• Maintain accurate, timely documentation in the electronic health record (EHR) according to regulatory and facility standards.
• Provide crisis intervention, grief counseling, and support to patients, families, and staff.
• Maintain strong working relationships with community agencies, law enforcement, protective services, tribal health entities, and public health partners.

Job Requirements:

Knowledge, Skills, and Abilities:

• Proficiently be able to read, write, speak, and understand the English language.
• Must be able to work independently and be able to work effectively as a team member.
• Familiarity with healthcare delivery systems, especially rural settings.
• Awareness of and sensitivity to diverse cultural, socioeconomic, and health-related backgrounds.
• Ability to assess and support individualized care plans.
• Strong written and verbal skills to interact with patients, families, and interdisciplinary teams.
• Skilled in advocating patients'/residents' needs and rights within healthcare systems and the community.
• Flexibility to address the unique challenges of providing services in rural healthcare systems.
• Demonstrate ability to provide emotional support to patients/residents and families facing challenging circumstances.
• Proficient in social services information systems.
• Ability to prioritize tasks and manage caseload efficiently.
• Strong interpersonal, organizational, and problem-solving skills.
• Familiarity with state and federal healthcare programs and regulations (e.g. Medicare, Medicaid).
• Strong communication and interpersonal skills to effectively interact with residents, families and healthcare team members.
• Knowledge of community resources and referral systems

Qualifications:

• Bachelor's degree in social work or related medical field OR 3-4 years relevant professional experience in social services, care coordination, and/or discharge planning may be considered in lieu of degree.
• 1-year social services related experience (nice to have).
• 1-year social work-related experience in healthcare setting (nice to have).
• Licensed Social Worker (LSW) or equivalent licensure where applicable (nice to have).
• Experience in working in long-term care settings, acute care and/or with social services.
• Must pass MN background check and fingerprinting.
• Complete TB test within the first 3 weeks of employment.

Work Schedule:

• Hallock, MN
• Monday – Friday 8:00 am – 4:30 pm or as needed by the department
• Hospital, Clinic, and Long-term care setting

Why Work With Us:

Full-Time/Part-Time Employee Benefits:

• Medical (select plans HSA-eligible with employer contribution)
• Dental and Vision – 100% employer-paid for single coverage
• Basic Life and AD&D – 100% employer-paid policy
• Optional employee-paid voluntary life and AD&D
• Paid Time Off (PTO) and Extended Time Off
• 403(b) retirement plan with 3% employer match
• Educational scholarships
• Employee Assistance Program (EAP)
• Shift differential pay
• Cell phone discount
• Rewarding and dynamic work environment
• Employer-paid CNA training and certification available

Flex Employee Benefits:

• 403(b) retirement plan with 3% employer match
• Educational scholarships
• Employee Assistance Program (EAP)
• Shift differential pay
• Cell phone discount
• Rewarding and dynamic work environment